DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: J0BU
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
Facility ID: 00227
3. NAME AND ADDRESS OF FACILITY
(L3) MARTIN LUTHER CARE CENTER
1. MEDICARE/MEDICAID PROVIDER NO.
245272
(L1)
(L4) 1401 EAST 100TH STREET
2.STATE VENDOR OR MEDICAID NO.
(L2)
180482000
7. PROVIDER/SUPPLIER CATEGORY
(L9) 01/01/2007
03/14/2016
6. DATE OF SURVEY
8. ACCREDITATION STATUS:
(a) :
To
(b) :
13 PTIP
(L34)
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
(L10)
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
FISCAL YEAR ENDING DATE:
(L35)
12/31
And/Or Approved Waivers Of The Following Requirements:
1. Acceptable POC
137 (L18)
137 (L17)
B. Not in Compliance with Program
Requirements and/or Applied Waivers:
2. Technical Personnel
6. Scope of Services Limit
3. 24 Hour RN
7. Medical Director
4. 7-Day RN (Rural SNF)
8. Patient Room Size
5. Life Safety Code
9. Beds/Room
A
* Code:
(L12)
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
4. CHOW
6. Complaint
9. Other
10.THE FACILITY IS CERTIFIED AS:
Program Requirements
Compliance Based On:
13.Total Certified Beds
2. Recertification
3. Termination
5. Validation
7. On-Site Visit
8. Full Survey After Complaint
22 CLIA
09 ESRD
A. In Compliance With
12.Total Facility Beds
1. Initial
(L7)
05 HHA
11. .LTC PERIOD OF CERTIFICATION
From
02
01 Hospital
1 TJC
3 Other
0 Unaccredited
2 AOA
(L6) 55425
(L5) BLOOMINGTON, MN
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
7 (L8)
4. TYPE OF ACTION:
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
137
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
17. SURVEYOR SIGNATURE
Date :
18. STATE SURVEY AGENCY APPROVAL
Date:
03/15/2016
Gayle Lantto, Unit Supervisor
03/15/2016
(L19)
(L20)
PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
X
20. COMPLIANCE WITH CIVIL
RIGHTS ACT:
1. Facility is Eligible to Participate
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
OF PARTICIPATION
24. LTC AGREEMENT
BEGINNING DATE
VOLUNTARY
ENDING DATE
02/01/1985
(L24)
(L41)
25. LTC EXTENSION DATE:
26. TERMINATION ACTION:
(L25)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
(L30)
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
(L31)
32. DETERMINATION OF APPROVAL DATE
31. RO RECEIPT OF CMS-1539
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
03/14/2016
(L33)
DETERMINATION APPROVAL
020499
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
CMS Certification Number (CCN): 245272
March 15, 2016
Ms. Jody Barney, Administrator
Martin Luther Care Center
1401 East 100th Street
Bloomington, Minnesota 55425
Dear Ms. Barney:
The Minnesota Department of Health assists the Centers for Medicare and Medicaid Services (CMS) by
surveying skilled nursing facilities and nursing facilities to determine whether they meet the requirements for
participation. To participate as a skilled nursing facility in the Medicare program or as a nursing facility in the
Medicaid program, a provider must be in substantial compliance with each of the requirements established by
the Secretary of Health and Human Services found in 42 CFR part 483, Subpart B.
Based upon your facility being in substantial compliance, we are recommending to CMS that your facility be
recertified for participation in the Medicare and Medicaid program the Minnesota Department of Human
Services that your facility is recertified in the Medicaid program.
Effective March 4, 2016 the above facility is certified for:
137
Skilled Nursing Facility/Nursing Facility Beds
Your facility’s Medicare approved area consists of all 137 skilled nursing facility beds.
You should advise our office of any changes in staffing, services, or organization, which might affect your
certification status.
If, at the time of your next survey, we find your facility to not be in substantial compliance your Medicare and
Medicaid provider agreement may be subject to non-renewal or termination.
Feel free to contact me if you have questions related to this eNotice.
Sincerely,
Mark Meath, Enforcement Specialist
Program Assurance Unit
Licensing and Certification Program
Health Regulation Division
Email: [email protected]
Telephone: (651) 201-4118 Fax: (651) 215-9697
An equal opportunity employer
PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS
Electronically delivered
March 15, 2016
Ms. Jody Barney, Administrator
Martin Luther Care Center
1401 East 100th Street
Bloomington, Minnesota 55425
RE: Project Number S5272025
Dear Ms. Barney:
On February 9, 2016, we informed you that we would recommend enforcement remedies based on the
deficiencies cited by this Department for a standard survey, completed on January 28, 2016. This survey
found the most serious deficiencies to be isolated deficiencies that constituted no actual harm with
potential for more than minimal harm that was not immediate jeopardy (Level D), hereby corrections were
required.
On March 14, 2016, the Minnesota Departments of Health conducted a Post Certification Revisit (PCR) by
review of your plan of correction and on March 14, 2016. the Department of Public Safety completed a
Post Certification Revisit (PCR) to verify that your facility had achieved and maintained compliance with
federal certification deficiencies issued pursuant to a standard survey, completed on January 28, 2016. We
presumed, based on your plan of correction, that your facility had corrected these deficiencies as of March
4, 2016. Based on our PCR, we have determined that your facility has corrected the deficiencies issued
pursuant to our standard survey, completed on January 28, 2016, effective March 4, 2016 and therefore
remedies outlined in our letter to you dated February 9, 2016, will not be imposed.
Please note, it is your responsibility to share the information contained in this letter and the results of this
visit with the President of your facility's Governing Body.
Feel free to contact me if you have questions related to this eNotice.
Sincerely,
Mark Meath, Enforcement Specialist
Program Assurance Unit
Licensing and Certification Program
Health Regulation Division
Minnesota Department of Health
Email: [email protected]
Telephone: (651) 201-4118 Fax: (651) 215-9697
An equal opportunity employer
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245272
Y1
MULTIPLE CONSTRUCTION
A. Building
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
3/14/2016
Y3
BLOOMINGTON, MN 55425
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
DATE
Y4
Y5
Y4
ID Prefix F0156
Correction
ID Prefix F0241
Completed
Reg. #
LSC
03/04/2016
ID Prefix F0309
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix F0282
Completed
Reg. #
LSC
03/04/2016
LSC
03/04/2016
Correction
ID Prefix F0356
Correction
ID Prefix F0431
Correction
Completed
Reg. #
Completed
Reg. #
LSC
03/04/2016
LSC
03/04/2016
LSC
03/04/2016
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
Reg. #
Reg. #
483.10(b)(5) - (10),
483.10(b)(1)
483.25
LSC
483.15(a)
483.30(e)
LSC
Correction
483.20(k)(3)(ii)
Completed
483.60(b), (d), (e)
Completed
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
DATE
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
DATE
GL/mm
FOLLOWUP TO SURVEY COMPLETED ON
1/28/2016
Form CMS - 2567B (09/92) EF (11/06)
SIGNATURE OF SURVEYOR
03/15/2016
DATE
15507
03/14/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
J0BU12
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245272
Y1
MULTIPLE CONSTRUCTION
A. Building 01 - MAIN BUILDING 01
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
3/14/2016
Y3
BLOOMINGTON, MN 55425
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
DATE
ITEM
DATE
Y5
Y4
Y5
Correction
ID Prefix
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
Reg. #
Completed
02/19/2016
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
Reg. #
LSC
NFPA 101
K0143
LSC
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
DATE
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
DATE
TL/mm
FOLLOWUP TO SURVEY COMPLETED ON
1/27/2016
Form CMS - 2567B (09/92) EF (11/06)
SIGNATURE OF SURVEYOR
03/15/2016
DATE
37009
03/14/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
J0BU22
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: J0BU
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
245272
(L1)
(L4) 1401 EAST 100TH STREET
2.STATE VENDOR OR MEDICAID NO.
(L2)
180482000
01 Hospital
01/28/2016
6. DATE OF SURVEY
8. ACCREDITATION STATUS:
0 Unaccredited
2 AOA
To
(b) :
05 HHA
09 ESRD
13 PTIP
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
2. Recertification
3. Termination
4. CHOW
5. Validation
6. Complaint
7. On-Site Visit
9. Other
FISCAL YEAR ENDING DATE:
(L35)
12/31
10.THE FACILITY IS CERTIFIED AS:
A. In Compliance With
And/Or Approved Waivers Of The Following Requirements:
Program Requirements
Compliance Based On:
1. Acceptable POC
12.Total Facility Beds
137 (L18)
13.Total Certified Beds
137 (L17)
X B. Not in Compliance with Program
Requirements and/or Applied Waivers:
2. Technical Personnel
6. Scope of Services Limit
3. 24 Hour RN
7. Medical Director
4. 7-Day RN (Rural SNF)
8. Patient Room Size
5. Life Safety Code
9. Beds/Room
(L12)
B*
* Code:
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
1. Initial
8. Full Survey After Complaint
22 CLIA
(L34)
1 TJC
3 Other
2 (L8)
(L7)
(L10)
11. .LTC PERIOD OF CERTIFICATION
(a) :
02
7. PROVIDER/SUPPLIER CATEGORY
01/01/2007
From
(L6) 55425
(L5) BLOOMINGTON, MN
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
(L9)
Facility ID: 00227
4. TYPE OF ACTION:
3. NAME AND ADDRESS OF FACILITY
(L3) MARTIN LUTHER CARE CENTER
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
137
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
See Attached Remarks
17. SURVEYOR SIGNATURE
Date :
18. STATE SURVEY AGENCY APPROVAL
Date:
03/03/2016
Sandra Tatro, HFE NEII
03/10/2016
(L19)
(L20)
PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
X
20. COMPLIANCE WITH CIVIL
RIGHTS ACT:
1. Facility is Eligible to Participate
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
OF PARTICIPATION
26. TERMINATION ACTION:
24. LTC AGREEMENT
BEGINNING DATE
ENDING DATE
VOLUNTARY
02/01/1985
(L24)
(L41)
25. LTC EXTENSION DATE:
(L25)
(L30)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
31. RO RECEIPT OF CMS-1539
32. DETERMINATION OF APPROVAL DATE
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
(L31)
(L33)
DETERMINATION APPROVAL
020499
DEPARTMENT OF HEALTH AND HUMAN SERVICES
C&T REMARKS - CMS 1539 FORM
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: J0BU
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
Facility ID: 00227
STATE AGENCY REMARKS
CCN: 24 5272
A standard survey was completed on January 28, 2016 to verify the facility was in compliance with Federal
certification regulations. Deficiencies were cited with the most serious deficiencies cited at a scope and
severity of E. The facility has been given an opportunity to correct before remedies would be imposed. In
addition at the time of the standard survey, investigation of complaint numbers H5272061 and H5272062
were conducted and both were found unsubstantiated. Post Certification Revisit (PCR) to follow. Refer to the
CMS 2567 forms (for both health and life safety code) along with the facility's plan of correction.
FORM CMS-1539 (7-84) (Destroy Prior Editions)
020499
Protecting, maintaining and improving the health of all Minnesotans
Electronically delivered
February 9, 2016
Ms. Jody Barney, Administrator
Martin Luther Care Center
1401 East 100th Street
Bloomington, MN 55425
RE: Project Number S5272025, H5272061, H5272062
Dear Ms. Barney:
On January 28, 2016, a standard survey was completed at your facility by the Minnesota Departments of
Health and Public Safety to determine if your facility was in compliance with Federal participation
requirements for skilled nursing facilities and/or nursing facilities participating in the Medicare and/or
Medicaid programs. This survey found the most serious deficiencies in your facility to be a pattern of
deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate
jeopardy (Level E), as evidenced by the attached CMS-2567 whereby corrections are required. A copy of the
Statement of Deficiencies (CMS-2567) is enclosed. In addition, at the time of the January 28, 2016 standard
survey the Minnesota Department of Health completed an investigation of complaint numbers H5272061 and
H5272062 that were found to be unsubstantiated.
Please note that this notice does not constitute formal notice of imposition of alternative remedies or
termination of your provider agreement. Should the Centers for Medicare & Medicaid Services determine
that termination or any other remedy is warranted, it will provide you with a separate formal notification of
that determination.
This letter provides important information regarding your response to these deficiencies and addresses the
following issues:
Opportunity to Correct - the facility is allowed an opportunity to correct identified deficiencies
before remedies are imposed;
Electronic Plan of Correction - when a plan of correction will be due and the information to be
contained in that document;
Remedies - the type of remedies that will be imposed with the authorization of the
Centers for Medicare and Medicaid Services (CMS) if substantial compliance is not attained at the
time of a revisit;
Potential Consequences - the consequences of not attaining substantial compliance 3 and 6 months
after the survey date; and
Informal Dispute Resolution - your right to request an informal reconsideration to dispute the
An equal opportunity employer
Martin Luther Care Center
February 9, 2016
Page 2
attached deficiencies.
Please note, it is your responsibility to share the information contained in this letter and the results of this visit
with the President of your facility's Governing Body.
DEPARTMENT CONTACT
Questions regarding this letter and all documents submitted as a response to the resident care deficiencies
(those preceded by a "F" tag), i.e., the plan of correction should be directed to:
Gayle Lantto, Unit Supervisor
Minnesota Department of Health
P.O. Box 64900
St. Paul, Minnesota 55164-0900
[email protected]
Telephone: (651) 201-3794
Fax: (651) 215-9697
OPPORTUNITY TO CORRECT - DATE OF CORRECTION - REMEDIES
As of January 14, 2000, CMS policy requires that facilities will not be given an opportunity to correct before
remedies will be imposed when actual harm was cited at the last standard or intervening survey and also cited
at the current survey. Your facility does not meet this criterion. Therefore, if your facility has not achieved
substantial compliance by March 8, 2016, the Department of Health will impose the following remedy:
•
State Monitoring. (42 CFR 488.422)
ELECTRONIC PLAN OF CORRECTION (ePoC)
An ePoC for the deficiencies must be submitted within ten calendar days of your receipt of this letter. Your
ePoC must:
-
Address how corrective action will be accomplished for those residents found to have been
affected by the deficient practice;
-
Address how the facility will identify other residents having the potential to be affected by the
same deficient practice;
-
Address what measures will be put into place or systemic changes made to ensure that the
deficient practice will not recur;
-
Indicate how the facility plans to monitor its performance to make sure that solutions are
sustained. The facility must develop a plan for ensuring that correction is achieved and
sustained. This plan must be implemented, and the corrective action evaluated for its
effectiveness. The plan of correction is integrated into the quality assurance system;
-
Include dates when corrective action will be completed. The corrective action
completion dates must be acceptable to the State. If the plan of correction is
Martin Luther Care Center
February 9, 2016
Page 3
unacceptable for any reason, the State will notify the facility. If the plan of correction is
acceptable, the State will notify the facility. Facilities should be cautioned that they are
ultimately accountable for their own compliance, and that responsibility is not alleviated
in cases where notification about the acceptability of their plan of correction is not made
timely. The plan of correction will serve as the facility’s allegation of compliance; and,
-
Submit electronically to acknowledge your receipt of the electronic 2567, your review and
your ePoC submission.
The state agency may, in lieu of a revisit, determine correction and compliance by accepting the facility's ePoC
if the ePoC is reasonable, addresses the problem and provides evidence that the corrective action has
occurred.
If an acceptable ePoC is not received within 10 calendar days from the receipt of this letter, we will
recommend to the CMS Region V Office that one or more of the following remedies be imposed:
•
Optional denial of payment for new Medicare and Medicaid admissions (42 CFR
488.417 (a));
•
Per day civil money penalty (42 CFR 488.430 through 488.444).
Failure to submit an acceptable ePoC could also result in the termination of your facility’s Medicare and/or
Medicaid agreement.
PRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCE
The facility's ePoC will serve as your allegation of compliance upon the Department's acceptance. Your
signature at the bottom of the first page of the CMS-2567 form will be used as verification of compliance. In
order for your allegation of compliance to be acceptable to the Department, the ePoC must meet the criteria
listed in the plan of correction section above. You will be notified by the Minnesota Department of Health,
Licensing and Certification Program staff and/or the Department of Public Safety, State Fire Marshal Division
staff, if your ePoC for the respective deficiencies (if any) is acceptable.
VERIFICATION OF SUBSTANTIAL COMPLIANCE
Upon receipt of an acceptable ePoC, an onsite revisit of your facility may be conducted to validate that
substantial compliance with the regulations has been attained in accordance with your verification. A Post
Certification Revisit (PCR) will occur after the date you identified that compliance was achieved in your plan of
correction.
If substantial compliance has been achieved, certification of your facility in the Medicare and/or
Medicaid program(s) will be continued and remedies will not be imposed. Compliance is certified as of the
latest correction date on the approved ePoC, unless it is determined that either correction actually occurred
between the latest correction date on the ePoC and the date of the first revisit, or correction occurred sooner
than the latest correction date on the ePoC.
Martin Luther Care Center
February 9, 2016
Page 4
Original deficiencies not corrected
If your facility has not achieved substantial compliance, we will impose the remedies described above. If the
level of noncompliance worsened to a point where a higher category of remedy may be imposed, we will
recommend to the CMS Region V Office that those other remedies be imposed.
Original deficiencies not corrected and new deficiencies found during the revisit
If new deficiencies are identified at the time of the revisit, those deficiencies may be disputed through the
informal dispute resolution process. However, the remedies specified in this letter will be imposed for original
deficiencies not corrected. If the deficiencies identified at the revisit require the imposition
of a higher category of remedy, we will recommend to the CMS Region V Office that those remedies be
imposed.
Original deficiencies corrected but new deficiencies found during the revisit
If new deficiencies are found at the revisit, the remedies specified in this letter will be imposed. If the
deficiencies identified at the revisit require the imposition of a higher category of remedy, we will recommend
to the CMS Region V Office that those remedies be imposed. You will be provided the required notice before
the imposition of a new remedy or informed if another date will be set for the imposition of these remedies.
FAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LAST DAY OF
THE SURVEY
If substantial compliance with the regulations is not verified by April 21, 2016 (three months after the
identification of noncompliance), the CMS Region V Office must deny payment for new admissions as
mandated by the Social Security Act (the Act) at Sections 1819(h)(2)(D) and 1919(h)(2)(C) and Federal
regulations at 42 CFR Section 488.417(b). This mandatory denial of payments will be based on the failure to
comply with deficiencies originally contained in the Statement of Deficiencies, upon the identification of new
deficiencies at the time of the revisit, or if deficiencies have been issued as the result of a complaint visit or
other survey conducted after the original statement of deficiencies was issued. This mandatory denial of
payment is in addition to any remedies that may still be in effect as of this date.
We will also recommend to the CMS Region V Office and/or the Minnesota Department of Human Services
that your provider agreement be terminated by July 21, 2016 (six months after the identification of
noncompliance) if your facility does not achieve substantial compliance. This action is mandated by the Social
Security Act at Sections 1819(h)(2)(C) and 1919(h)(3)(D) and Federal regulations at 42 CFR Sections 488.412
and 488.456.
INFORMAL DISPUTE RESOLUTION
In accordance with 42 CFR 488.331, you have one opportunity to question cited deficiencies through an
informal dispute resolution process. You are required to send your written request, along with the specific
deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to:
Nursing Home Informal Dispute Process
Minnesota Department of Health
Health Regulation Division
Martin Luther Care Center
February 9, 2016
Page 5
P.O. Box 64900
St. Paul, Minnesota 55164-0900
This request must be sent within the same ten days you have for submitting an ePoC for the cited deficiencies.
All requests for an IDR or IIDR of federal deficiencies must be submitted via the web at:
http://www.health.state.mn.us/divs/fpc/profinfo/ltc/ltc_idr.cfm
You must notify MDH at this website of your request for an IDR or IIDR within the 10 calendar day period
allotted for submitting an acceptable plan of correction. A copy of the Department’s informal dispute
resolution policies are posted on the MDH Information Bulletin website at:
http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm
Please note that the failure to complete the informal dispute resolution process will not delay the dates
specified for compliance or the imposition of remedies.
Questions regarding all documents submitted as a response to the Life Safety Code deficiencies (those
preceded by a "K" tag), i.e., the plan of correction, request for waivers, should be directed to:
Tom Linhoff, Fire Safety Supervisor
Health Care Fire Inspections
State Fire Marshal Division
Email: [email protected]
Phone: (651) 430-3012
Fax: (651) 215-0525
Feel free to contact me if you have questions.
Sincerely,
Kamala Fiske-Downing, Program Specialist
Licensing and Certification Program
Health Regulation Division
Minnesota Department of Health
[email protected]
Telephone: (651) 201-4112 Fax: (651) 215-9697
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 000 INITIAL COMMENTS
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 000
The facility's plan of correction (POC) will serve
as your allegation of compliance upon the
Department's acceptance. Because you are
enrolled in ePOC, your signature is not required
at the bottom of the first page of the CMS-2567
form. Your electronic submission of the POC will
be used as verification of compliance.
Upon receipt of an acceptable electronic POC, an
on-site revisit of your facility may be conducted to
validate that substantial compliance with the
regulations has been attained in accordance with
your verification.
Complaints H5272061 and H5272062 were
investigated at the time of the recertification
survey and were found to be unsubstantiated.
F 156 483.10(b)(5) - (10), 483.10(b)(1) NOTICE OF
SS=D RIGHTS, RULES, SERVICES, CHARGES
F 156
3/4/16
The facility must inform the resident both orally
and in writing in a language that the resident
understands of his or her rights and all rules and
regulations governing resident conduct and
responsibilities during the stay in the facility. The
facility must also provide the resident with the
notice (if any) of the State developed under
§1919(e)(6) of the Act. Such notification must be
made prior to or upon admission and during the
resident's stay. Receipt of such information, and
any amendments to it, must be acknowledged in
writing.
The facility must inform each resident who is
entitled to Medicaid benefits, in writing, at the time
of admission to the nursing facility or, when the
resident becomes eligible for Medicaid of the
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Electronically Signed
(X6) DATE
02/19/2016
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 1 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 156 Continued From page 1
items and services that are included in nursing
facility services under the State plan and for
which the resident may not be charged; those
other items and services that the facility offers
and for which the resident may be charged, and
the amount of charges for those services; and
inform each resident when changes are made to
the items and services specified in paragraphs (5)
(i)(A) and (B) of this section.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 156
The facility must inform each resident before, or
at the time of admission, and periodically during
the resident's stay, of services available in the
facility and of charges for those services,
including any charges for services not covered
under Medicare or by the facility's per diem rate.
The facility must furnish a written description of
legal rights which includes:
A description of the manner of protecting personal
funds, under paragraph (c) of this section;
A description of the requirements and procedures
for establishing eligibility for Medicaid, including
the right to request an assessment under section
1924(c) which determines the extent of a couple's
non-exempt resources at the time of
institutionalization and attributes to the community
spouse an equitable share of resources which
cannot be considered available for payment
toward the cost of the institutionalized spouse's
medical care in his or her process of spending
down to Medicaid eligibility levels.
A posting of names, addresses, and telephone
numbers of all pertinent State client advocacy
groups such as the State survey and certification
agency, the State licensure office, the State
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 2 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 156 Continued From page 2
ombudsman program, the protection and
advocacy network, and the Medicaid fraud control
unit; and a statement that the resident may file a
complaint with the State survey and certification
agency concerning resident abuse, neglect, and
misappropriation of resident property in the
facility, and non-compliance with the advance
directives requirements.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 156
The facility must inform each resident of the
name, specialty, and way of contacting the
physician responsible for his or her care.
The facility must prominently display in the facility
written information, and provide to residents and
applicants for admission oral and written
information about how to apply for and use
Medicare and Medicaid benefits, and how to
receive refunds for previous payments covered by
such benefits.
This REQUIREMENT is not met as evidenced
by:
Based on interview and document review, the
facility failed to provide liability notices for 1 of 3
residents (R148) reviewed for liability notices and
beneficiary appeal rights.
Findings include:
R148's Admission Records dated 10/24/15,
indicated the resident was admitted to the facility
on 10/24/15, and discharged on 11/14/15. While
at the facility, R148 was receiving physical and
occupational therapy services.
On 1/28/16, at approximately 2:00 p.m. the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Submission of this Allegation of
Compliance is not a legal admission that a
deficiency exists or that this Statement of
Deficiencies was correctly cited and is
also not to be construed as an admission
against the Facility, Administrator, of any
Employees, Agents or other individuals
who draft or may be discussed in the
Allegation of Compliance. In addition,
preparation and submission of the
Allegation of Compliance does not
constitute an admission or an agreement
of any kind by the Facility of the truth of
any facts alleged or the correctness of any
Facility ID: 00227
If continuation sheet Page 3 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 156 Continued From page 3
Notices of Medicare Non-Coverage were
requested from the facility. R148's Notices of
Medicare Non-Coverage form indicated that
services would end on 11/13/15. However, the
form was neither signed or dated, nor was there
indication whether R148 ever received the notice.
On 1/28/16, at 2:25 p.m. a clinical reimbursement
specialist (CRS) was interviewed, and explained
therapy staff usually provided notification when a
resident's services were ending and she then
notified the resident or family and had the form
signed. The CRS confirmed that R148's form had
not been signed and stated, "I'm not sure how
this happened." The CRS was unsure whether
R148 ever received the notice. The CRS
explained, "We are supposed to notify the
resident at least two days prior to their service
ending," and R148's services ended on 11/13/15,
and was discharged the following day.
The facility's 9/13, Medicare Denial policy directed
that, "The facility must notify the
patient/responsible party at least two days prior to
skilled care ending that Medicare benefits will
end. The facility must issue an Skilled Nursing
Facility Advance Beneficiary Notice (SNFABN)
(form CMS 10055) and completed copy of the
Notice of Medicare Non-Coverage (NOMNC)
(form CMS 10123)...Ensure beneficiary signs and
dates."
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 156
conclusions set forth in the Statement by
the survey agency.
Accordingly, the Facility has prepared and
submitted this Allegation of Compliance
solely because of the requirements under
State and Federal law that mandate
submission of an Allegation of
Compliance within ten days of receipt of
the Statement of Deficiencies as a
condition of participation in Title 18 and
Title 19 programs. The submission of this
Allegation of Compliance within this time
frame should in no way be considered or
construed as an agreement with
allegations of noncompliance or
admissions by the facility.
This plan of correction is not to be
construed as an admission by the facility
or any of its agents that the survey
agents findings in this report are true or
correct. The plan of correction is written
for the purpose of compliance with the
rules of participation for the Medicaid and
Medicare programs.
Resident 148 discharged from the facility
on 11/14/15, therefore, it is not
appropriate to issue a Notice of Medicare
Non-Coverage now.
Current residents, whose Medicare
benefits will be ending, will be audited to
ensure liability notices have been or will
be provided to those residents.
The Medicare A Denial policy will be
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 4 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 156 Continued From page 4
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 156
reviewed and revised as needed.
Re-education will be provided to the
Clinical Reimbursement Specialist and
potential designee(s) on the revised policy
and process.
Random audits will be completed weekly
by the Administrator or designee(s) for
three months to ensure compliance.
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Administrator is responsible for
compliance.
F 241 483.15(a) DIGNITY AND RESPECT OF
SS=D INDIVIDUALITY
F 241
3/4/16
The facility must promote care for residents in a
manner and in an environment that maintains or
enhances each resident's dignity and respect in
full recognition of his or her individuality.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to provide 1 of 14
residents (R104) a dignified dining experience.
Resident 104's care plan was updated to
reflect the resident s desire to eat with
her fingers and plan to provide
appropriate finger foods.
Findings include:
R104 was observed eating with her fingers
without staff intervention on 1/25/16, at 5:50 p.m.
R104 fed herself pasta with seafood cream sauce
and green beans which was pureed (smooth,
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Review and revise Meal Service policy,
which includes dignified dining, and
re-educate staff on revised policy.
Will complete weekly random dining room
Facility ID: 00227
If continuation sheet Page 5 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 241 Continued From page 5
pudding-like consistency) with her fingers while a
nursing assistant (NA)-A was at the table
assisting another resident to eat. R104 was licked
the food from her fingers throughout the meal. At
6:18 p.m. R104 finished eating and after NA-A
assisted her from the dining room, she explained
R104 did not wear dentures and normally ate with
her fingers.
The following day at 12:20 p.m. R104 was totally
assisted to eat. On 1/27/16, at 9:30 a.m. R104
fed herself breakfast which included ground
sausage and scrambled eggs with her fingers,
licking her fingers throughout the meal.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 241
audits to ensure dignified dining
experience with current residents.
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Director of Nursing is responsible for
compliance.
During an interview on 1/27/16, at 12:56 p.m. with
NA-B who consistently worked with R104, the NA
stated the resident "loves to eat with her fingers"
and generally did not allow staffs' assistance to
eat.
R104's quarterly Minimum Data Set (MDS) dated
11/5/15, identified the resident had dementia with
severely impaired cognition. The resident
required limited assistance with eating a
mechanically altered (texture) diet. R104's
current physician orders included "regular diet,
dysphagia 3 [or DD3 for swallowing disorder]
texture, thin consistency, refusing to wear
dentures."
R104's care plan dated 11/9/15, identified the
potential for alteration in nutrition related to
dementia an the need for a mechanically altered
diet due to refusal to wear dentures; the resident
required "some assist" with meals. Interventions
directed staff to provide the physician prescribed
diet with thin liquids, and to supervise the resident
at mealtime due to her cognitive status. Staff was
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 6 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 241 Continued From page 6
to open and pour liquids, cut up foods and spread
condiments as needed. The care plan did not
address the resident's desire to eat with her
fingers, nor a plan for the provision of appropriate
finger foods.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 241
A registered nurse (RN)-A explained on 1/27/16,
at approximately 3:00 p.m. R104's mood changed
from day to day and occasionally she allowed
staff assistance to eat. RN-A stated the resident
did better with sandwiches and had difficulty
grasping silverware with her fingers. RN-A
reported that although the resident was
prescribed a DD3 diet, she was able to eat
sandwiches and "loves bread with jelly." RN-A
said staff should have tried to offer R104 finger
foods.
RN-B stated on 1/27/16, at 4:55 p.m. if R104 was
able to manipulate silverware, she may have
been be able to feed herself but if she was having
difficulty, she could have been provided finger
foods like bread with jelly or some toast. If she
left the table she also could have been provided
finger foods so she could walk around and still
eat. RN-A reviewed the care plan and verified it
did not include interventions related to the inability
to utilize silverware. At approximately 5:00 p.m.
RN-B provided an undated Modified Texture and
Thickened Liquids guide. The guide indicated a
DD3 diet "requires more chewing than DD2 diet,
no hard or crusty foods, tailored more for oral
control problems than swallowing problems.
Meats may be chopped or ground and served
with gravy or sauce. Rice should be pureed."
A related policy was requested on 1/27/16, but
was not provided.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 7 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 282 Continued From page 7
F 282 483.20(k)(3)(ii) SERVICES BY QUALIFIED
SS=D PERSONS/PER CARE PLAN
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
F 282
F 282
(X5)
COMPLETION
DATE
3/4/16
The services provided or arranged by the facility
must be provided by qualified persons in
accordance with each resident's written plan of
care.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to follow the care plan for
dialysis access site care to minimize the risk of
infection and clotting for 1 of 1 resident (R248)
reviewed for dialysis.
Findings include:
R248's care plan initiated 9/16/15, identified the
resident had a diagnosis of chronic renal failure
and received dialysis three times weekly. The
plan directed staff to check bruit and thrill daily,
take vital signs daily and as needed, observe
dialysis access site every shift and report
negative findings/changes to the physician and
dialysis center staff. If bleeding occurred at the
access site, staff was directed to apply pressure
until the bleeding stopped, and to notify the
physician and dialysis center staff. The plan also
directed staff to "remove dressing from access
site six hours after dialysis, and wash access site
daily with cares--do not scrub vigorously."
On 1/28/16, at 11:32 p.m. RN-B stated the
guidelines and care plan to manage the dialysis
site were from R248's first admission to the
facility. (The Admission Record dated 1/28/16,
revealed and admission date of 11/16/15.) She
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Resident 282's care plan was reviewed.
Treatment sheet was updated to reflect
appropriate monitoring.
All current residents receiving dialysis will
have their care plan audited to ensure
compliance.
The Individualized Care Plan and Care
Cards policy was reviewed and revised.
Re-education with the Inter-Disciplinary
Team (IDT) members on Care Plan and
Care Cards policy and compliance.
Weekly random audits will be completed
to ensure care plans are followed.
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Director of Nursing is responsible for
compliance.
Facility ID: 00227
If continuation sheet Page 8 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 282 Continued From page 8
explained that when R248 returned from the
hospital the physician orders had not been
transcribed to the medication administration
record (MAR) or the treatment administration
record (TAR). "Honestly, if it is not on the MAR or
TAR it probably is not being done."
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 282
The facility's 12/13, Policy/Procedure Series
Subject Dialysis Resident--Care directed staff to
"assess patient complication post dialysis therapy
to assess internal accesses (fistulas and grafts):
for infection--warmth, pain, redness, swelling,
discharge, tenderness (assess daily),
dressing--remove Band-Aids or gauze 4 hours
after discharge from dialysis, clotted
access--notify the dialysis unit or the nephrologist,
hematoma--apply ice to the site for 24 hours then
apply warm packs, access bleeding post
dialysis--apply direct pressure to site for 10
minutes."
The facility's 12/13, Individualized Care Plan and
Care Cards policy indicated "a resident profile will
be maintained accurate with information identified
on the Resident Care Plan. The Profile should be
reviewed at each quarterly update of care plan to
assure all information is timely and accurate."
In an interview with the director of nursing on
1/28/16, at 1:30 p.m. it was stated the expectation
was for the care plan to be up-to-date and
followed by staff.
F 309 483.25 PROVIDE CARE/SERVICES FOR
SS=D HIGHEST WELL BEING
F 309
3/4/16
Each resident must receive and the facility must
provide the necessary care and services to attain
or maintain the highest practicable physical,
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 9 of 19
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FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 309 Continued From page 9
mental, and psychosocial well-being, in
accordance with the comprehensive assessment
and plan of care.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to ensure services were
provided to a dialysis access site to minimize the
risk of infection and clotting for 1 of 1 resident
(R248) reviewed for dialysis.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 309
Resident 248's care plan was reviewed.
Treatment sheet was updated to reflect
appropriate monitoring.
Review and revise Individualized Care
Plan and Care Cards policy.
Findings include:
R248 was observed on 1/27/16, at approximately
8:30 a.m. in his room. There was no dressing to
dialysis access site observed on the resident's left
upper arm. A licensed practical nurse (LPN)-B
stated R248 went to dialysis on Monday,
Wednesday and Friday each week. LPN-B stated
she did not manage his dialysis access site or
dressing and was unaware of what was actually
related to R248's dressing after 3:00 p.m. as she
was off duty.
On 1/28/16, at 8:37 a.m. R248 was again lying in
bed. No dressing was observed on his left upper
extremity access site. When asked who had
removed the dressing he stated he had because
it was itching. He further explained he always
removed the dressing and denied nurses in the
facility had ever managed the site or removed the
dressing.
Re-education with the Inter-Disciplinary
Team (IDT) members and Licensed
Nursing on Individualized Care Plan and
Care Cards policy and revising, updating,
and following care plans. Review care of
dialysis residents with IDT and Licensed
Nursing.
Weekly random audits will be completed
to ensure compliance with following care
plan.
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Director of Nursing is responsible for
compliance.
R248's care plan initiated 9/16/15, revealed the
resident had a diagnosis of chronic renal failure
and received dialysis three times weekly. The
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 10 of 19
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FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 309 Continued From page 10
plan directed staff to "check bruit and thrill daily
[to ensure proper function of the site], take vital
signs daily and as needed, observe dialysis
access site every shift and report negative
findings/changes to the physician and dialysis
center staff. If bleeding occurred at the access
site, staff was directed to apply pressure until the
bleeding stopped, and to notify the physician and
dialysis center staff...remove dressing from
access site six hours after dialysis, and wash
access site daily with cares--do not scrub
vigorously."
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 309
Although the Minimum Data Set dated 1/11/16,
identified R248 to had moderate cognitive
impairment, it also indicated he had the ability to
understand others, had clear comprehension,
clear speech and the ability to express ideas and
wants.
Review of the 1/16, TAR revealed R248 was
receiving Coumadin. The TAR directed staff to:
"observe fistula/graft for patency: Feel for thrill,
listen with stethoscope for bruit. Notify MD and
dialysis for absence of sound. Write a progress
note for absence of sound and notify [nurse
practitioner/physician] (nursing order) in the
morning for dialysis monitoring. Order date
1/28/16."
The 11/15, 12/15 and through 1/28/16 TAR
lacked direction to monitor or document the
condition of the dialysis access site for R248.
However the TAR from this time period did direct
staff to remove the bandage every night on
Monday, Wednesday and Friday because R248
had some skin breakdown from the tape.
An interview was conducted with a registered
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 11 of 19
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FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 309 Continued From page 11
nurse (RN)-B on 1/28/16, at 8:44 a.m. R248
reportedly had dialysis three days weekly. The
facility did not have an emergency plan or
supplies to manage residents receiving dialysis
should he have been unable to receive dialysis.
She further explained that although he rarely
missed dialysis, there was not an emergency plan
in place if should R248 be unable or restricted
from getting to the dialysis facility. RN-B said
there was a physician's order directing nursing
staff to remove the dressing "at night," however, it
was not noted on the treatment administration
record (TAR). I was an expectation of RN-B that
staff "re-wrap it if it is bleeding and to call the
doctor if it is infected." RN-B also explained R248
was prescribed the blood thinner, Coumadin and
heart medication, so close monitoring was
required because the resident had "very thin
blood," however, because there was no direction
on the TAR or medication administration record
(MAR) and she was unsure if it was being
regularly documented.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 309
Later at 11:02 a.m. LPN-B stated R248's dressing
was always removed by morning and and LPN-B
therefore, did not document monitoring of bruit
and thrill or clotting at the dialysis site.
On 1/28/16, at 11:10 a.m. the dialysis nurse
(RN-C) from DaVita Dialysis stated R248 was
originally given guidelines to manage the access
site for clotting and infection and when he was
placed on dialysis services. However, when he
admitted to the long term care facility, the papers
would not have followed the resident, and the
facility had not requested verbal or written
instructions related to managing the dialysis
access site for R248. She stated she expected
the facility would remove the dressing the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 12 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 309 Continued From page 12
morning following dialysis, and monitor the site at
least daily for clotting and clotting, and infection.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 309
On 1/28/16, at 11:32 p.m. RN-B stated the
guidelines and care plan to manage the dialysis
site were from R248's first admission to the
facility. (The Admission Record dated 1/28/16,
revealed and admission date of 11/16/15.) She
explained that when R248 returned from the
hospital the physician orders had not been
transcribed to the medication administration
record (MAR) or the treatment administration
record (TAR). "Honestly, if it is not on the MAR or
TAR it probably is not being done."
An interview on 1/28/16, at 1:39 p.m. the director
of nursing revealed that when R248 returned from
the hospital his orders were not transcribed to the
MAR. "The problem is that unit does not get a lot
of dialysis residents and it was missed. He [R248]
has a lot of orders. There should have been two
checks. It was missed. I would expect this to be
followed through."
The facility's 12/13, Policy/Procedure Series
Subject Dialysis Resident--Care directed staff to
"assess patient complication post dialysis therapy
to assess internal accesses (fistulas and grafts):
for infection--warmth, pain, redness, swelling,
discharge, tenderness (assess daily),
dressing--remove Band-Aids or gauze 4 hours
after discharge from dialysis, clotted
access--notify the dialysis unit or the nephrologist,
hematoma--apply ice to the site for 24 hours then
apply warm packs, access bleeding post
dialysis--apply direct pressure to site for 10
minutes."
The undated DaVita Dialysis Guidelines directed
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 13 of 19
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FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 309 Continued From page 13
staff to: "Check dressing site daily...Monitor,
document and report prn any s/sx [as needed
signs and symptoms] of infection to access site:
redness, swelling, warmth or drainage."
F 356 483.30(e) POSTED NURSE STAFFING
SS=C INFORMATION
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 309
F 356
3/4/16
The facility must post the following information on
a daily basis:
o Facility name.
o The current date.
o The total number and the actual hours worked
by the following categories of licensed and
unlicensed nursing staff directly responsible for
resident care per shift:
- Registered nurses.
- Licensed practical nurses or licensed
vocational nurses (as defined under State law).
- Certified nurse aides.
o Resident census.
The facility must post the nurse staffing data
specified above on a daily basis at the beginning
of each shift. Data must be posted as follows:
o Clear and readable format.
o In a prominent place readily accessible to
residents and visitors.
The facility must, upon oral or written request,
make nurse staffing data available to the public
for review at a cost not to exceed the community
standard.
The facility must maintain the posted daily nurse
staffing data for a minimum of 18 months, or as
required by State law, whichever is greater.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 14 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 356 Continued From page 14
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to post the required
nurse staffing information to reflect actual hours
worked for licensed staff on all shifts as required.
This practice had the potential to affect all 130
residents in the facility and visitors.
Findings include:
During initial tour of the facility, on 1/25/16, at
approximately 11:45 p.m. the staffs' Projected
Nurse Staffing Information dated 1/25/16, was
observed on the wall adjacent to the desk near
the main entrance.
1) For the 6:30 a.m. to 3:00 p.m. were: five
registered nurses (RNs), seven licensed practical
nurses (LPNs), and 16 nursing assistants (NAs)
from 6:00 a.m. to 2:00 p.m.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 356
Posted actual hours were available in a
binder just below the posted projected
daily hours. Therefore, this did not directly
impact any residents or visitors.
We reviewed and revised the Nursing
Staffing Hours policy and provided
re-education to the staff responsible for
posting hours.
Weekly random audits will be completed
to ensure compliance.
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Director of Nursing is responsible for
compliance.
2) For 2:30 p.m. through 11:00 p.m. were: six
RNs, five LPNs, and two NAs from 3:00 p.m. to
11:00 p.m. and 14 NAs from 2:00 p.m. to 10:00
p.m.
3) For 10:30 p.m. through 7:00 a.m. were: two
RNs, three LPNs, and five NAs from 10:00 p.m.
to 6:00 a.m. and 2 NAs from 11:00 p.m. to 7:00
a.m.
The total projected nursing hours for 1/25/16,
was: 104 RN hours, 120 LPN hours and 292.5 NA
hours. The posted census was 129 residents for
long and short term care.
A three-ringed binder labeled Actual Nurse
Staffing Information was on a shelf below the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 15 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 356 Continued From page 15
posted staffing hours labeled Projected Nursing
Staffing Information.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 356
On 1/26/16, 8:15 a.m. the Projected Staff Nursing
information was again posted on the wall
adjacent to the desk near the main entrance. The
three-ringed binder Actual Nurse Staffing
Information was below the posting on a shelf.
Included in the binder was the Actual Staff
Posting Information dated 1/25/16.
The nursing staff actual hours for 1/25/16 were as
follows:
1) For 6:30 a.m. through 3:00 p.m. were four
RNs, six LPNs, two trained medication aides
(TMAs and 13 NAs from 6:00 a.m. to 2:00 p.m.
2) For 2:30 p.m. through 11:00 p.m. were six
RNs, three LPNs, two TMAs and 12 NAs from
2:00 p.m. to 10.:00 p.m. and 1 NAs from 3:00
p.m. to 11:03 p.m.
3) For 10:30 p.m. to 7:00 a.m. were three RNs,
one LPN, one TMA, five NAs from 10:00 p.m. to
6:00 a.m. and two NAs from 11:00 p.m. to 7:00
a.m.
The total actual nursing hours for 1/25/16, was
109 RN hours, 83.75 LPN hours, 39.25 TMA
hours and 261.25 NA. The posted census was
130 residents for long and short term care.
This practice was also observed 1/26/16, 1/27/16
and 1/28/16.
During an interview on 1/27/16, at 10:27 a.m. the
staffing coordinator explained he completed The
Projected Staff Nursing Information sheet for the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 16 of 19
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FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 356 Continued From page 16
following day and gave it to the receptionist
before he left for the day. The following day the
receptionist posted the projected hours at
approximately 8:00 a.m. He did not update or
verify the posting during the day but was
instructed to put The Actual Staff Nursing
Information sheet in a binder at the reception
desk near the front entrance.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 356
The facility's 8/20/14, Policy/Procedure Series
Nursing Staffing Hours directed "staff must post
the the total number of actual hours worked for:
registered nurses, licensed practical nurses and
certified nursing assistants."
An interview with the director of nursing (DON) on
1/28/16, at 1:30 p.m. revealed the daily staff
posting was a projection of hours of work for
licensed nursing staff and NAs. Actual hours
worked by nursing staff was not posted, but
instead was placed in a book near the reception
area. The DON further explained the staff
information was not updated with changes.
F 431 483.60(b), (d), (e) DRUG RECORDS,
SS=D LABEL/STORE DRUGS & BIOLOGICALS
F 431
3/4/16
The facility must employ or obtain the services of
a licensed pharmacist who establishes a system
of records of receipt and disposition of all
controlled drugs in sufficient detail to enable an
accurate reconciliation; and determines that drug
records are in order and that an account of all
controlled drugs is maintained and periodically
reconciled.
Drugs and biologicals used in the facility must be
labeled in accordance with currently accepted
professional principles, and include the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 17 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 431 Continued From page 17
appropriate accessory and cautionary
instructions, and the expiration date when
applicable.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 431
In accordance with State and Federal laws, the
facility must store all drugs and biologicals in
locked compartments under proper temperature
controls, and permit only authorized personnel to
have access to the keys.
The facility must provide separately locked,
permanently affixed compartments for storage of
controlled drugs listed in Schedule II of the
Comprehensive Drug Abuse Prevention and
Control Act of 1976 and other drugs subject to
abuse, except when the facility uses single unit
package drug distribution systems in which the
quantity stored is minimal and a missing dose can
be readily detected.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to ensure expired
tuberculin solution was not available for use for 1
of 4 medication storage areas reviewed. This has
the potential to affect 15 residents residing on the
unit.
We could not identify any residents who
were affected from this as there were no
new admissions to that unit.
All refrigerators were checked for expired
medications to ensure no other residents
could be impacted.
Findings include:
During observation of the medication storage
area on 1/27/16, at 10:59 a.m. an opened box
which contained a multi-dose bottle of tuberculin
purified derivative, (sterile aqueous solution to
tuberculosis testing) was observed stored in the
refrigerator. The date on the box indicated the
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
We reviewed and revised the
Administration Procedures for all
Medications Long-Term Care policy and
provided re-education to the nursing staff.
Weekly random audits will be completed
to ensure compliance.
Facility ID: 00227
If continuation sheet Page 18 of 19
PRINTED: 03/03/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245272
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/28/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
1401 EAST 100TH STREET
MARTIN LUTHER CARE CENTER
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 431 Continued From page 18
medication was opened 11/18/15. The bottle of
tuberculin indicated approximately half of the
medication was used (approximately five doses
administered).
In an interview with a licensed practical nurse
(LPN)-A on 1/27/16, at 10:59 a.m. she stated she
was unaware how long tuberculin solution could
be used once opened.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 431
A summary of the audits will be reviewed
at the Quality Assurance & Performance
Improvement (QAPI) Committee for 3
months and the recommendations from
the Committee will be followed. The
Director of Nursing is responsible for
compliance.
During interview with the registered nurse (RN)-B
on 1/27/16, at 11:03 a.m. she also states he was
unaware how long tuberculin solutions would be
considered viable once opened, and would need
to check the facility's policy.
The facility's undated medication listing "These
Mediations Need Expiration Stickers" and
included Tubersol Apisol was to be stored in the
refrigerator and "expired after 30 days."
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: J0BU11
Facility ID: 00227
If continuation sheet Page 19 of 19
Protecting, maintaining and improving the health of all Minnesotans
Electronically submitted
February 9, 2016
Ms. Jody Barney, Administrator
Martin Luther Care Center
1401 East 100th Street
Bloomington, MN 55425
Re: Enclosed State Nursing Home Licensing Orders - Project Number S5272025
Dear Ms. Barney:
The above facility was surveyed on January 25, 2016 through January 28, 2016 for the purpose of assessing
compliance with Minnesota Department of Health Nursing Home Rules and to investigate complaint numbers
H5272061 and H5272062 that was found to be unsubstantiated. At the time of the survey, the survey team
from the Minnesota Department of Health, Health Regulation Division, noted one or more violations of these
rules that are issued in accordance with Minnesota Stat. section 144.653 and/or Minnesota Stat. Section
144A.10. If, upon reinspection, it is found that the deficiency or deficiencies cited herein are not corrected, a
civil fine for each deficiency not corrected shall be assessed in accordance with a schedule of fines
promulgated by rule of the Minnesota Department of Health.
To assist in complying with the correction order(s), a “suggested method of correction” has been added. This
provision is being suggested as one method that you can follow to correct the cited deficiency. Please
remember that this provision is only a suggestion and you are not required to follow it. Failure to follow the
suggested method will not result in the issuance of a penalty assessment. You are reminded, however, that
regardless of the method used, correction of the deficiency within the established time frame is required. The
“suggested method of correction” is for your information and assistance only.
You have agreed to participate in the electronic receipt of State licensure orders consistent with the
Minnesota Department of Health Informational Bulletin 14-01, available at
http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm . The State licensing orders are delineated on
the attached Minnesota Department of Health orders being submitted to you electronically. The Minnesota
Department of Health is documenting the State Licensing Correction Orders using federal software. Tag
numbers have been assigned to Minnesota state statutes/rules for Nursing Homes.
The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute/rule number
and the corresponding text of the state statute/rule out of compliance is listed in the "Summary Statement of
Deficiencies" column and replaces the "To Comply" portion of the correction order. This column also includes
the findings that are in violation of the state statute after the statement, "This Rule is not met as evidenced
by." Following the surveyors findings are the Suggested Method of Correction and the Time Period For
Correction.
PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,
"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES
ONLY. THIS WILL APPEAR ON EACH PAGE.
An equal opportunity employer
Martin Luther Care Center
February 9, 2016
Page 2
THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE
STATUTES/RULES.
Although no plan of correction is necessary for State Statutes/Rules, please enter the word "corrected" in the
box available for text. You must then indicate in the electronic State licensure process, under the heading
completion date, the date your orders will be corrected prior to electronically submitting to the Minnesota
Department of Health. We urge you to review these orders carefully, item by item, and if you find that any of
the orders are not in accordance with your understanding at the time of the exit conference following the
survey, you should contact Gayle Lantto, at 651-201-3794.
You may request a hearing on any assessments that may result from non-compliance with these orders
provided that a written request is made to the Department within 15 days of receipt of a notice of assessment
for non-compliance.
Please note it is your responsibility to share the information contained in this letter and the results of this visit
with the President of your facility’s Governing Body.
Please feel free to call me with any questions.
Sincerely,
Kamala Fiske-Downing, Program Specialist
Licensing and Certification Program
Health Regulation Division
Minnesota Department of Health
[email protected]
Telephone: (651) 201-4112
Fax: (651) 215-9697
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
(X4) ID
PREFIX
TAG
2 000 Initial Comments
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
*****ATTENTION******
NH LICENSING CORRECTION ORDER
In accordance with Minnesota Statute, section
144A.10, this correction order has been issued
pursuant to a survey. If, upon reinspection, it is
found that the deficiency or deficiencies cited
herein are not corrected, a fine for each violation
not corrected shall be assessed in accordance
with a schedule of fines promulgated by rule of
the Minnesota Department of Health.
Determination of whether a violation has been
corrected requires compliance with all
requirements of the rule provided at the tag
number and MN Rule number indicated below.
When a rule contains several items, failure to
comply with any of the items will be considered
lack of compliance. Lack of compliance upon
re-inspection with any item of multi-part rule will
result in the assessment of a fine even if the item
that was violated during the initial inspection was
corrected.
You may request a hearing on any assessments
that may result from non-compliance with these
orders provided that a written request is made to
the Department within 15 days of receipt of a
notice of assessment for non-compliance.
INITIAL COMMENTS:
You have agreed to participate in the electronic
receipt of State licensure orders consistent with
the Minnesota Department of Health
Informational Bulletin 14-01, available at
http://www.health.state.mn.us/divs/fpc/profinfo/inf
obul.htm The State licensing orders are
delineated on the attached Minnesota
Minnesota Department of Health
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Electronically Signed
STATE FORM
(X6) DATE
02/19/16
6899
J0BU11
If continuation sheet 1 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Continued From page 1
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
Department of Health orders being submitted to
you electronically. Although no plan of correction
is necessary for State Statutes/Rules, please
enter the word "corrected" in the box available for
text. You must then indicate in the electronic
State licensure process, under the heading
completion date, the date your orders will be
corrected prior to electronically submitting to the
Minnesota Department of Health.
On January 25, 26, 27, and 28, 2016 surveyors of
this Department's staff, visited the above provider
and the following correction orders are issued.
Please indicate in your electronic plan of
correction that you have reviewed these orders,
and identify the date when they will be completed.
Minnesota Department of Health is documenting
the State Licensing Correction Orders using
federal software. Tag numbers have been
assigned to Minnesota state statutes/rules for
Nursing Homes.
The assigned tag number appears in the far left
column entitled "ID Prefix Tag." The state
statute/rule out of compliance is listed in the
"Summary Statement of Deficiencies" column
and replaces the "To Comply" portion of the
correction order. This column also includes the
findings which are in violation of the state statute
after the statement, "This Rule is not met as
evidence by." Following the surveyors findings
are the Suggested Method of Correction and
Time period for Correction.
PLEASE DISREGARD THE HEADING OF THE
FOURTH COLUMN WHICH STATES,
"PROVIDER'S PLAN OF CORRECTION." THIS
APPLIES TO FEDERAL DEFICIENCIES ONLY.
THIS WILL APPEAR ON EACH PAGE.
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 2 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Continued From page 2
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
THERE IS NO REQUIREMENT TO SUBMIT A
PLAN OF CORRECTION FOR VIOLATIONS OF
MINNESOTA STATE STATUTES/RULES.
Complaints H5272061 and H5272062 were
investigated at the time of the licensing survey
and were found unsubstantiated.
2 565 MN Rule 4658.0405 Subp. 3 Comprehensive
2 565
3/4/16
Plan of Care; Use
Subp. 3. Use. A comprehensive plan of care
must be used by all personnel involved in the
care of the resident.
This MN Requirement is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to follow the care plan for
dialysis access site care to minimize the risk of
infection and clotting for 1 of 1 resident (R248)
reviewed for dialysis.
We have reviewed these orders.
Findings include:
R248's care plan initiated 9/16/15, identified the
resident had a diagnosis of chronic renal failure
and received dialysis three times weekly. The
plan directed staff to check bruit and thrill daily,
take vital signs daily and as needed, observe
dialysis access site every shift and report
negative findings/changes to the physician and
dialysis center staff. If bleeding occurred at the
access site, staff was directed to apply pressure
until the bleeding stopped, and to notify the
physician and dialysis center staff. The plan also
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 3 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 565 Continued From page 3
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 565
directed staff to "remove dressing from access
site six hours after dialysis, and wash access site
daily with cares--do not scrub vigorously."
On 1/28/16, at 11:32 p.m. RN-B stated the
guidelines and care plan to manage the dialysis
site were from R248's first admission to the
facility. (The Admission Record dated 1/28/16,
revealed and admission date of 11/16/15.) She
explained that when R248 returned from the
hospital the physician orders had not been
transcribed to the medication administration
record (MAR) or the treatment administration
record (TAR). "Honestly, if it is not on the MAR or
TAR it probably is not being done."
The facility's 12/13, Policy/Procedure Series
Subject Dialysis Resident--Care directed staff to
"assess patient complication post dialysis therapy
to assess internal accesses (fistulas and grafts):
for infection--warmth, pain, redness, swelling,
discharge, tenderness (assess daily),
dressing--remove Band-Aids or gauze 4 hours
after discharge from dialysis, clotted
access--notify the dialysis unit or the nephrologist,
hematoma--apply ice to the site for 24 hours then
apply warm packs, access bleeding post
dialysis--apply direct pressure to site for 10
minutes."
The facility's 12/13, Individualized Care Plan and
Care Cards policy indicated "a resident profile will
be maintained accurate with information identified
on the Resident Care Plan. The Profile should be
reviewed at each quarterly update of care plan to
assure all information is timely and accurate."
In an interview with the director of nursing on
1/28/16, at 1:30 p.m. it was stated the expectation
was for the care plan to be up-to-date and
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 4 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 565 Continued From page 4
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 565
followed by staff.
SUGGESTED METHOD OF CORRECTION:
The facility could review policies and procedures
for revision of the care plan, provide education to
nursing staff pertaining to the follow through of
the care plan, then develop and implement an
auditing system to ensure on-going compliance.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days.
2 830 MN Rule 4658.0520 Subp. 1 Adequate and
2 830
3/4/16
Proper Nursing Care; General
Subpart 1. Care in general. A resident must
receive nursing care and treatment, personal and
custodial care, and supervision based on
individual needs and preferences as identified in
the comprehensive resident assessment and
plan of care as described in parts 4658.0400 and
4658.0405. A nursing home resident must be out
of bed as much as possible unless there is a
written order from the attending physician that the
resident must remain in bed or the resident
prefers to remain in bed.
This MN Requirement is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to ensure services were
provided to a dialysis access site to minimize the
risk of infection and clotting for 1 of 1 resident
(R248) reviewed for dialysis.
We have reviewed these orders.
Findings include:
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 5 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 830 Continued From page 5
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 830
R248 was observed on 1/27/16, at approximately
8:30 a.m. in his room. There was no dressing to
dialysis access site observed on the resident's left
upper arm. A licensed practical nurse (LPN)-B
stated R248 went to dialysis on Monday,
Wednesday and Friday each week. LPN-B stated
she did not manage his dialysis access site or
dressing and was unaware of what was actually
related to R248's dressing after 3:00 p.m. as she
was off duty.
On 1/28/16, at 8:37 a.m. R248 was again lying in
bed. No dressing was observed on his left upper
extremity access site. When asked who had
removed the dressing he stated he had because
it was itching. He further explained he always
removed the dressing and denied nurses in the
facility had ever managed the site or removed the
dressing.
R248's care plan initiated 9/16/15, revealed the
resident had a diagnosis of chronic renal failure
and received dialysis three times weekly. The
plan directed staff to "check bruit and thrill daily
[to ensure proper function of the site], take vital
signs daily and as needed, observe dialysis
access site every shift and report negative
findings/changes to the physician and dialysis
center staff. If bleeding occurred at the access
site, staff was directed to apply pressure until the
bleeding stopped, and to notify the physician and
dialysis center staff...remove dressing from
access site six hours after dialysis, and wash
access site daily with cares--do not scrub
vigorously."
Although the Minimum Data Set dated 1/11/16,
identified R248 to had moderate cognitive
impairment, it also indicated he had the ability to
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 6 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 830 Continued From page 6
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 830
understand others, had clear comprehension,
clear speech and the ability to express ideas and
wants.
Review of the 1/16, TAR revealed R248 was
receiving Coumadin. The TAR directed staff to:
"observe fistula/graft for patency: Feel for thrill,
listen with stethoscope for bruit. Notify MD and
dialysis for absence of sound. Write a progress
note for absence of sound and notify [nurse
practitioner/physician] (nursing order) in the
morning for dialysis monitoring. Order date
1/28/16."
The 11/15, 12/15 and through 1/28/16 TAR
lacked direction to monitor or document the
condition of the dialysis access site for R248.
However the TAR from this time period did direct
staff to remove the bandage every night on
Monday, Wednesday and Friday because R248
had some skin breakdown from the tape.
An interview was conducted with a registered
nurse (RN)-B on 1/28/16, at 8:44 a.m. R248
reportedly had dialysis three days weekly. The
facility did not have an emergency plan or
supplies to manage residents receiving dialysis
should he have been unable to receive dialysis.
She further explained that although he rarely
missed dialysis, there was not an emergency plan
in place if should R248 be unable or restricted
from getting to the dialysis facility. RN-B said
there was a physician's order directing nursing
staff to remove the dressing "at night," however, it
was not noted on the treatment administration
record (TAR). I was an expectation of RN-B that
staff "re-wrap it if it is bleeding and to call the
doctor if it is infected." RN-B also explained R248
was prescribed the blood thinner, Coumadin and
heart medication, so close monitoring was
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 7 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 830 Continued From page 7
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 830
required because the resident had "very thin
blood," however, because there was no direction
on the TAR or medication administration record
(MAR) and she was unsure if it was being
regularly documented.
Later at 11:02 a.m. LPN-B stated R248's dressing
was always removed by morning and and LPN-B
therefore, did not document monitoring of bruit
and thrill or clotting at the dialysis site.
On 1/28/16, at 11:10 a.m. the dialysis nurse
(RN-C) from DaVita Dialysis stated R248 was
originally given guidelines to manage the access
site for clotting and infection and when he was
placed on dialysis services. However, when he
admitted to the long term care facility, the papers
would not have followed the resident, and the
facility had not requested verbal or written
instructions related to managing the dialysis
access site for R248. She stated she expected
the facility would remove the dressing the
morning following dialysis, and monitor the site at
least daily for clotting and clotting, and infection.
On 1/28/16, at 11:32 p.m. RN-B stated the
guidelines and care plan to manage the dialysis
site were from R248's first admission to the
facility. (The Admission Record dated 1/28/16,
revealed and admission date of 11/16/15.) She
explained that when R248 returned from the
hospital the physician orders had not been
transcribed to the medication administration
record (MAR) or the treatment administration
record (TAR). "Honestly, if it is not on the MAR or
TAR it probably is not being done."
An interview on 1/28/16, at 1:39 p.m. the director
of nursing revealed that when R248 returned from
the hospital his orders were not transcribed to the
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 8 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 830 Continued From page 8
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 830
MAR. "The problem is that unit does not get a lot
of dialysis residents and it was missed. He [R248]
has a lot of orders. There should have been two
checks. It was missed. I would expect this to be
followed through."
The facility's 12/13, Policy/Procedure Series
Subject Dialysis Resident--Care directed staff to
"assess patient complication post dialysis therapy
to assess internal accesses (fistulas and grafts):
for infection--warmth, pain, redness, swelling,
discharge, tenderness (assess daily),
dressing--remove Band-Aids or gauze 4 hours
after discharge from dialysis, clotted
access--notify the dialysis unit or the nephrologist,
hematoma--apply ice to the site for 24 hours then
apply warm packs, access bleeding post
dialysis--apply direct pressure to site for 10
minutes."
The undated DaVita Dialysis Guidelines directed
staff to: "Check dressing site daily...Monitor,
document and report prn any s/sx [as needed
signs and symptoms] of infection to access site:
redness, swelling, warmth or drainage."
SUGGESTED METHOD OF CORRECTION:
The facility could review their policies and
procedures, provide staff education pertaining to
the revision of care plan with any change of
condition or physician recommendation, and
develop and/or implement an auditing system to
ensure on-going compliance. Audits could be
conducted and the results brought to the quality
committee for review.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days.
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 9 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
ID
PREFIX
TAG
21426 Continued From page 9
21426
21426 MN St. Statute 144A.04 Subd. 3 Tuberculosis
21426
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
3/4/16
Prevention And Control
(a) A nursing home provider must establish and
maintain a comprehensive tuberculosis
infection control program according to the most
current tuberculosis infection control guidelines
issued by the United States Centers for Disease
Control and Prevention (CDC), Division of
Tuberculosis Elimination, as published in CDC's
Morbidity and Mortality Weekly Report (MMWR).
This program must include a tuberculosis
infection control plan that covers all paid and
unpaid employees, contractors, students,
residents, and volunteers. The Department of
Health shall provide technical assistance
regarding implementation of the guidelines.
(b) Written compliance with this subdivision must
be maintained by the nursing home.
This MN Requirement is not met as evidenced
by:
Based on interview and document review, the
facility did not ensure State guidelines to ensure
Employee Tuberculosis (TB) Screening,
Tuberculin Skin Test (TST) and medical
evaluations for 3 of 5 employees (E1, E2, E3)
was completed prior to employment in the facility.
In addition 3 of 5 residents (R5, R117, R248) did
not receive TB screening or TST testing in a
timely manner.
We have reviewed these orders.
Findings include:
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 10 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 10
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21426
A review of employee files revealed E-1 had a
start date of 12/14/15. A TB symptom screen and
the first-step TST was done on 12/14/15. A
second TST, a blood test or a chest x-ray was not
completed. E-2 had a start date, symptom screen
and first step TST on 10/19/15. A second TST, a
blood test or a chest x-ray was not completed.
E-3 had a start date of 11/23/15. A TB symptom
screen was also done on her date-of-hire. The
first-step TST was done on 12/14/15. A second
TST, a blood test or a chest x-ray was not
completed. E-4's start date was 11/16/15. A TB
symptom screen was done 11/16/15. Although
the facility did a second step TST on 11/16/15,
the first-step TST from prior employment was
completed 5/11/15.
A review of resident immunization record
revealed R5 was admitted 1/14/16. A TB
symptom screen was done 11/3/15 and TST was
given on 11/4/15. No other indication of TB
testing was found in her record. R117 and R248
were admitted on 11/16/15 and also completed a
TB screen on this day. No TB testing was found
in either resident record.
The Ebenezer Policy/Procedure Series
Tuberculosis Screening- Resident, effective date
1/15, states: It is the policy to provide
identification of past exposure or active
Tuberculosis for each resident admission and to
establish a TST baseline for future reference.
Upon admission all residents will be assessed for
symptoms of and risk factors for tuberculosis
AND have a 2-step TST unless otherwise
indicated
The Ebenezer Policy/Procedure Series
Tuberculosis Screening- Employee, effective date
7/15, states: It is the policy to follow State
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 11 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 11
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21426
requirements regarding Tuberculosis screening of
all employees with past exposure to or active
tuberculosis at time of hire, and to establish a
TST baseline for future reference. All employees
will be screened for symptoms of and risk factors
tuberculosis AND have a 2-step TST unless
otherwise indicated. First step TST to be done
upon hire. Second -step TST will be done 1-3
weeks after first TST.
An interview with the director of nursing on (DON)
1/27/16, at approximately 2:15 p.m., revealed the
infection control nurse responsible for tracking
tuberculosis screening and testing for both staff
and residents had quit within the last several
months. She verified staff and residents TST
were not completed as per their policy. The DON
explained that she and another staff member
were "trying to catch-up". She stated all
employees and residents were to have a TB
screening and TST series completed upon
admission or hire unless a chest x-ray had been
done.
SUGGESTED METHOD OF CORRECTION: The
director of nursing could in-service the staff
responsible for completing and monitoring the TB
program to ensure it is consistent with current TB
requirements. Audits could be conducted and the
results brought to the quality committee for
review.
TIME PERIOD FOR CORRECTION: Fourteen
(14) days
21620 MN Rule 4658.1345 Labeling of Drugs
21620
3/4/16
Drugs used in the nursing home must be labeled
in accordance with part 6800.6300.
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 12 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21620 Continued From page 12
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21620
This MN Requirement is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to ensure expired
tuberculin solution was not available for use for 1
of 4 medication storage areas reviewed. This has
the potential to affect 15 residents residing on the
unit.
We have reviewed these orders.
Findings include:
During observation of the medication storage
area on 1/27/16, at 10:59 a.m. an opened box
which contained a multi-dose bottle of tuberculin
purified derivative, (sterile aqueous solution to
tuberculosis testing) was observed stored in the
refrigerator. The date on the box indicated the
medication was opened 11/18/15. The bottle of
tuberculin indicated approximately half of the
medication was used (approximately five doses
administered).
In an interview with a licensed practical nurse
(LPN)-A on 1/27/16, at 10:59 a.m. she stated she
was unaware how long tuberculin solution could
be used once opened.
During interview with the registered nurse (RN)-B
on 1/27/16, at 11:03 a.m. she also states he was
unaware how long tuberculin solutions would be
considered viable once opened, and would need
to check the facility's policy.
The facility's undated medication listing "These
Mediations Need Expiration Stickers" and
included Tubersol Apisol was to be stored in the
refrigerator and "expired after 30 days."
SUGGESTED METHOD OF CORRECTION:
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 13 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21620 Continued From page 13
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21620
The pharmacist and/or director of nursing could
in-service all staff responsible for medications the
need to secure medications and follow disposal of
medications according to the facility
policy/procedure. Audits could be conducted and
the results brought to the quality committee for
review.
TIME PERIOD FOR CORRECTION: Fourteen
(14) days.
21800 MN St. Statute144.651 Subd. 4 Patients &
21800
3/4/16
Residents of HC Fac.Bill of Rights
Subd. 4. Information about rights. Patients and
residents shall, at admission, be told that there
are legal rights for their protection during their
stay at the facility or throughout their course of
treatment and maintenance in the community and
that these are described in an accompanying
written statement of the applicable rights and
responsibilities set forth in this section. In the
case of patients admitted to residential programs
as defined in section 253C.01, the written
statement shall also describe the right of a
person 16 years old or older to request release as
provided in section 253B.04, subdivision 2, and
shall list the names and telephone numbers of
individuals and organizations that provide
advocacy and legal services for patients in
residential programs. Reasonable
accommodations shall be made for those with
communication impairments and those who
speak a language other than English. Current
facility policies, inspection findings of state and
local health authorities, and further explanation of
the written statement of rights shall be available
to patients, residents, their guardians or their
chosen representatives upon reasonable request
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 14 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21800 Continued From page 14
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21800
to the administrator or other designated staff
person, consistent with chapter 13, the Data
Practices Act, and section 626.557, relating to
vulnerable adults.
This MN Requirement is not met as evidenced
by:
Based on interview and document review, the
facility failed to provide liability notices for 1 of 3
residents (R148) reviewed for liability notices and
beneficiary appeal rights.
We have reviewed these orders.
Findings include:
R148's Admission Records dated 10/24/15,
indicated the resident was admitted to the facility
on 10/24/15, and discharged on 11/14/15. While
at the facility, R148 was receiving physical and
occupational therapy services.
On 1/28/16, at approximately 2:00 p.m. the
Notices of Medicare Non-Coverage were
requested from the facility. R148's Notices of
Medicare Non-Coverage form indicated that
services would end on 11/13/15. However, the
form was neither signed or dated, nor was there
indication whether R148 ever received the notice.
On 1/28/16, at 2:25 p.m. a clinical reimbursement
specialist (CRS) was interviewed, and explained
therapy staff usually provided notification when a
resident's services were ending and she then
notified the resident or family and had the form
signed. The CRS confirmed that R148's form had
not been signed and stated, "I'm not sure how
this happened." The CRS was unsure whether
R148 ever received the notice. The CRS
explained, "We are supposed to notify the
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 15 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21800 Continued From page 15
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21800
resident at least two days prior to their service
ending," and R148's services ended on 11/13/15,
and was discharged the following day.
The facility's 9/13, Medicare Denial policy directed
that, "The facility must notify the
patient/responsible party at least two days prior to
skilled care ending that Medicare benefits will
end. The facility must issue an Skilled Nursing
Facility Advance Beneficiary Notice (SNFABN)
(form CMS 10055) and completed copy of the
Notice of Medicare Non-Coverage (NOMNC)
(form CMS 10123)...Ensure beneficiary signs and
dates."
SUGGESTED METHOD OF CORRECTION: The
facility could review their policies and procedures,
provide staff re-education regarding liability
notices and beneficiary appeal rights, and
develop and/or implement an auditing system to
ensure on-going compliance. Audits could be
conducted and the results brought to the quality
committee for review.
TIME PERIOD FOR CORRECTION: Fourteen
(14) days.
21805 MN St. Statute 144.651 Subd. 5 Patients &
21805
3/4/16
Residents of HC Fac.Bill of Rights
Subd. 5. Courteous treatment. Patients and
residents have the right to be treated with
courtesy and respect for their individuality by
employees of or persons providing service in a
health care facility.
This MN Requirement is not met as evidenced
by:
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 16 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21805 Continued From page 16
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21805
We have reviewed these orders.
Based on observation, interview, and document
review, the facility failed to provide 1 of 14
residents (R104) a dignified dining experience.
Findings include:
R104 was observed eating with her fingers
without staff intervention on 1/25/16, at 5:50 p.m.
R104 fed herself pasta with seafood cream sauce
and green beans which was pureed (smooth,
pudding-like consistency) with her fingers while a
nursing assistant (NA)-A was at the table
assisting another resident to eat. R104 was licked
the food from her fingers throughout the meal. At
6:18 p.m. R104 finished eating and after NA-A
assisted her from the dining room, she explained
R104 did not wear dentures and normally ate with
her fingers.
The following day at 12:20 p.m. R104 was totally
assisted to eat. On 1/27/16, at 9:30 a.m. R104
fed herself breakfast which included ground
sausage and scrambled eggs with her fingers,
licking her fingers throughout the meal.
During an interview on 1/27/16, at 12:56 p.m. with
NA-B who consistently worked with R104, the NA
stated the resident "loves to eat with her fingers"
and generally did not allow staffs' assistance to
eat.
R104's quarterly Minimum Data Set (MDS) dated
11/5/15, identified the resident had dementia with
severely impaired cognition. The resident
required limited assistance with eating a
mechanically altered (texture) diet. R104's
current physician orders included "regular diet,
dysphagia 3 [or DD3 for swallowing disorder]
texture, thin consistency, refusing to wear
dentures."
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 17 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21805 Continued From page 17
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21805
R104's care plan dated 11/9/15, identified the
potential for alteration in nutrition related to
dementia an the need for a mechanically altered
diet due to refusal to wear dentures; the resident
required "some assist" with meals. Interventions
directed staff to provide the physician prescribed
diet with thin liquids, and to supervise the resident
at mealtime due to her cognitive status. Staff was
to open and pour liquids, cut up foods and spread
condiments as needed. The care plan did not
address the resident's desire to eat with her
fingers, nor a plan for the provision of appropriate
finger foods.
A registered nurse (RN)-A explained on 1/27/16,
at approximately 3:00 p.m. R104's mood changed
from day to day and occasionally she allowed
staff assistance to eat. RN-A stated the resident
did better with sandwiches and had difficulty
grasping silverware with her fingers. RN-A
reported that although the resident was
prescribed a DD3 diet, she was able to eat
sandwiches and "loves bread with jelly." RN-A
said staff should have tried to offer R104 finger
foods.
RN-B stated on 1/27/16, at 4:55 p.m. if R104 was
able to manipulate silverware, she may have
been be able to feed herself but if she was having
difficulty, she could have been provided finger
foods like bread with jelly or some toast. If she
left the table she also could have been provided
finger foods so she could walk around and still
eat. RN-A reviewed the care plan and verified it
did not include interventions related to the inability
to utilize silverware. At approximately 5:00 p.m.
RN-B provided an undated Modified Texture and
Thickened Liquids guide. The guide indicated a
DD3 diet "requires more chewing than DD2 diet,
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 18 of 19
PRINTED: 03/03/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00227
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
MARTIN LUTHER CARE CENTER
1401 EAST 100TH STREET
BLOOMINGTON, MN 55425
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21805 Continued From page 18
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/28/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21805
no hard or crusty foods, tailored more for oral
control problems than swallowing problems.
Meats may be chopped or ground and served
with gravy or sauce. Rice should be pureed."
A related policy was requested on 1/27/16, but
was not provided.
SUGGESTED METHOD OF CORRECTION: The
facility could review their policies and procedures,
provide staff education pertaining to dignity in the
dining rooms, and develop and/or implement an
auditing system to ensure on-going compliance.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days.
Minnesota Department of Health
STATE FORM
6899
J0BU11
If continuation sheet 19 of 19